Q: What dietary recommendations (including sodium and fluid) are effective for the treatment of adults with postural orthostatic tachycardia syndrome (POTS), including POTS as a complication post-COVID-19 syndrome (long COVID)?
Last Updated: 2023-07-27
Key Practice Point #1
Recommendation
Postural orthostatic tachycardia syndrome (POTS) has been reported as a postinfectious complication of COVID-19. Diet is recommended as a first-line treatment for POTS.
For the management of POTS, fair evidence suggests beneficial effects from:
- Increasing sodium intake to 10-12 g salt/day spread throughout the day as added salt or salt tablets. It is recommended to consult with the medical team regarding sodium goals, especially for those with co-morbidities (e.g. hypertension, renal disease).
Limited evidence suggests the following dietary recommendations can improve or stabilize POTS symptoms:
- Consume 2-3 L water/day (starting fluids early in the morning before rising).
- Avoid alcohol, caffeine and dehydration.
- Consume small, frequent meals and lower glycemic carbohydrates.
- Higher reported rates of the following conditions in individuals with POTS suggest screening and treating for the following: digestive symptoms (including irritable bowel syndrome), celiac disease, eating disorders and nutrient deficiencies (including iron-deficiency anemia).
Evidence Summary
Recommendations are based on empirical evidence reported in guidelines and narrative reviews
Grade of Evidence C, except for the salt recommendation, which was based on a randomized crossover study that found that a high sodium compared to a low sodium diet (6.9 versus 230 mg/day) was helpful in improving POTS but did not completely normalize symptoms
Grade of Evidence B.
Remarks
Postural orthostatic tachycardia syndrome (also known as dysautonomia) is a chronic disorder of the autonomic nervous system that is characterized by an increase in heart rate on standing. Symptoms include lightheadedness, palpitations, mental clouding (brain fog), headache, nausea, blurred vision, sleep disturbances, fatigue and gastrointestinal pain. Viral infections have been identified as a trigger for POTS and POTS has been reported as a postinfectious complication after COVID-19. No medications are approved for treating POTS.
10 g salt/NaCl (~2 tsp) = 3940 mg (171 mmol) sodium; 12 g salt = 4720 mg (206 mmol) sodium.
Increasing sodium intake can increase plasma and blood volume, which can improve tachycardia/orthostatic intolerance on standing.
Evidence
- A 2022 narrative review examining dietary and lifestyle intervention for the treatment of POTS identified that diet is a first-line treatment for POTS (1). The following dietary recommendations were provided:
- Increase Fluids and Salt: 2-3 L water/day and 10-12 g salt (NaCl)/day (as tolerated) from high salt foods, salt sticks and tablets are recommended. This is based on a 2015 Heart Rhythm Society Expert Consensus Statement and a 2020 Canadian Cardiovascular Society Position Statement on POTS, based on empirical evidence that these strategies increase blood volume and improve orthostatic intolerance. The only trial identified was a 2021 randomized crossover study in 14 women with POTS and 13 healthy controls (aged 23-49 years) who received high sodium (300 mmol/6.9 g/day) or low sodium diets (10 mmol/230 mg/day) for six days (2). All meals were provided, and water was consumed ad libitum. In POTS, the high sodium diet compared to the low sodium diet increased plasma volume, decreased the change in heart rate and lowered norepinephrine levels (a marker of sympathetic nervous system tone); however, women with POTS still met the criteria for POTS (change in heart of ≥30 bpm on standing) and the symptom scores were higher than healthy controls. The authors of the study concluded that volume depletion did not completely explain POTS and although treatment with a high sodium diet was helpful, it did not normalize symptoms (2). The authors of the narrative review caution that for individuals with other co-morbidities (hypertension, renal disease or cardiac conditions), sodium intake should be customized in consultation with the medical team (1). If no sodium goal is provided, it is suggested to start with 6 g/day salt spread throughout the day, increasing gradually as tolerated up to 10-12 g/day. Empirical evidence suggests starting fluids early in the morning even before arising.
- Avoid Alcohol, Caffeine and Dehydration: based on a narrative review, it is suggested that individuals avoid alcohol, caffeine and dehydration, which may exacerbate symptoms of POTS.
- General Nutrition Recommendations: include small, frequent meals and consuming lower glycemic carbohydrates, based on empirical evidence that these suggestions support glycemic balance and may reduce postprandial hypotension.
- Other Nutrition-related Conditions: that have a higher prevalence in individuals with POTS than the general population include irritable bowel syndrome, iron-deficiency anemia, gastroparesis and celiac disease. This was based on a 2019 survey of participants with POTS who reported a physician’s diagnosis of common conditions. In addition, a higher prevalence of disordered eating was reported from a retrospective chart review of adolescents and young adults diagnosed with POTS. The authors of the review recommend screening for these conditions and treating them as appropriate.
Comments
Postural orthostatic tachycardia syndrome (also known as dysautonomia) is a chronic disorder of the autonomic nervous system that is characterized by tachycardia (an increase in heart rate of ≥30 bpm) within 10 minutes of standing (3). Symptoms include lightheadedness, palpitations, mental clouding (brain fog), headache, nausea, blurred vision, sleep disturbances, fatigue and gastrointestinal pain. Viral infections have been identified as a trigger for POTS and several studies have reported the development of POTS as a postinfectious complication after COVID-19 (1). No medications are approved for treating POTS; diet is recommended as a first-line therapy for treatment (3).
10 g salt/NaCl (~2 tsp) = 3940 mg (171 mmol) sodium; 12 g salt = 4720 mg (206 mmol) sodium (4).
Rationale
A high sodium intake can increase plasma volume, which may reduce tachycardia/orthostatic intolerance on standing (3).
References
- Harris CI. COVID-19 Increases the Prevalence of Postural Orthostatic Tachycardia Syndrome: What Nutrition and Dietetics Practitioners Need to Know. J Acad Nutr Diet. 2022 Sep;122(9):1600-1605. doi: 10.1016/j.jand.2022.06.002. Epub 2022 Jun 10. PMID: 35697326; PMCID: PMC9186518. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/35697326/
- Garland EM, Gamboa A, Nwazue VC, Celedonio JE, Paranjape SY, Black BK, Okamoto LE, Shibao CA, Biaggioni I, Robertson D, Diedrich A, Dupont WD, Raj SR. Effect of High Dietary Sodium Intake in Patients With Postural Tachycardia Syndrome. J Am Coll Cardiol. 2021 May 4;77(17):2174-2184. doi: 10.1016/j.jacc.2021.03.005. PMID: 33926653; PMCID: PMC8103825. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/33926653/
- Lei LY, Chew DS, Sheldon RS, Raj SR. Evaluating and managing postural tachycardia syndrome. Cleve Clin J Med. 2019 May;86(5):333-344. doi: 10.3949/ccjm.86a.18002. PMID: 31066664. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/31066664/
- National Academies Press. Dietary Reference intakes for Water, Potassium, Sodium, Chloride and Sultfate; 2005. Available from: https://nap.nationalacademies.org/read/10925/chapter/1